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Mel Pohl M.D., FASAM
Mel Pohl M.D., FASAM
Chronic Pain

Chronic Pain: It Is All in Your Head, and It’s Real

The reality of emotions and how they affect our experience of pain.

In a previous post, I shared five of the most surprising lessons I’ve learned about chronic pain from treating patients over the last six years. I now want to expand on the first two: that all pain is real, and that emotions drive the experience of pain. These two points are inextricably linked, and I want to clear up some common misconceptions about the connection between the two.

All Pain Is Real

When I meet with physicians and families about someone with chronic pain, the question I often hear is, “Does he or she really have pain?” The answer I always give is “yes—all pain is real.” A person’s experience of pain is unique to the individual, and it can’t be measured from the outside, with the exception of sophisticated brain mapping available with a functional MRI, which is only in a few laboratories across the country. Since there’s really no way to know how much pain people are in except for what they tell you, my first inclination is to believe what my patients tell me.

No Brain, No Pain

Since the experience of chronic pain is subjective, it is often labeled “psychosomatic,” implying that the pain is psychologically driven. This brings up the natural question as to whether such pain is somehow less important or less “real” than “physical” pain based on visible X-ray changes and sensory input from the nervous system. What I want to explain is that these two cannot be separated: all pain is regulated by the brain—whether there is an actual nail in your thumb or an old injury that should have healed by now but inexplicably keeps hurting—in both cases it is nerve fibers that are sending messages to your brain that cause you to feel pain.

Chronic Pain and the Brain

Chronic pain refers to pain that continues after an acute injury heals or after the passing of a period of time that should allow for healing. Often, for unknown reasons, the injury or tissue damage doesn’t heal as expected, and because of this, the nerve fibers continue to fire as if there is damage that needs attention. With this unrelenting signal traveling up the spinal column to the brain, eventually the transmission circuits become more efficient at transmitting these signals—like a one-lane road becoming a four-lane highway. The continuous input into these circuits causes more transmission, with the net result being more pain. At the same time, the number and array of pain-causing neurotransmitters in the nervous system increase. Over time, the threshold for the pain receptors to fire is lowered, and a less intense stimulus is needed to cause the nerve to discharge and send its signal. What started out as a message from the site of an injury to the brain has become a self-contained feedback loop within the nervous system—a disease of the brain.

Are Emotions Real?

In an earlier post, I had mentioned that I’ve come to believe that 80 percent of the experience of chronic pain is emotional. Some took issue with this and assumed I was saying that 80 percent of chronic pain is “only in your heads,” and therefore not real. As I’ve explained above, nothing could be further from the truth. Saying that the experience of chronic pain is emotional does not in any way change the reality, the validity, the structure of it—nor its intensity. It’s not about whether it’s real, but rather the universal, integrated way in which the brain processes sensory and emotional experiences which ultimately results in the experience we know as pain.

Emotions, just like pain, are creations of the physical brain, specifically the midbrain. Emotions emerge from a complex interaction of electrical and chemical impulses in the brain, resulting in a cascade of nerves firing and chemicals being secreted. Neurotransmitters are involved with the experience of pain as well as with emotions. They are responsible for sending information between nerves about the pain and/or emotions being sensed. The main area of the brain where we form and register emotions is the limbic system—a set of midbrain structures surrounding the thamalus, which is the pain-processing center responsible for filtering and prioritizing all the impulses the brain receives.

Pain Experienced as Emotion

When I ask patients about their pain, 8 out of 10 words they use to describe their experience are emotional. The three most frequently used terms are anxiety, fear, and anger, but there’s also depression, helplessness, loss of purpose, frustration, guilt, and shame. Pain is protective, and when we feel pain, we experience a set of aversive emotions so that we attempt to move away from whatever is causing it. That’s how we’re circuited. So it’s logical that we would have an emotional response to pain. “As pain becomes chronic, the sensory components become less important and the emotional and behavioral components tend to take on more importance,” says Jodie Ann Trafton, director of the Veterans Administration Palo Alto Health Care Systems Program Evaluation and Resource center in California. “This is because of learning. Having pain is a strong emotional experience. It will reshape your behavior. It will reshape how you interact with the world. And that in itself means your brain is going to respond differently over time.”

Emotions Drive the Experience of Pain

Based on studies conducted earlier this year and published in the journal Nature Neuroscience, we now have conclusive evidence that the experience of chronic pain is strongly influenced by emotions. The emotional state of the brain can explain why different individuals do not respond the same way to similar injuries. It was possible to predict with 85 percent accuracy whether an individual (out of a group of forty volunteers who each received four brain scans over the course of one year) would go on to develop chronic pain after an injury, or not. These results echo other data and studies in the psychological and medical literature that confirm that changing one’s attitudes—one’s emotions—toward pain decreases the pain.


I believe that one of the most important things people with chronic pain can do to help themselves is to notice what they are feeling. Every individual has a unique experience of pain, but in this discussion, I focus on some of the universal elements. Especially in our culture, where we resist pain and want to move away from it at all cost, we create a vicious cycle where our attempts to move away from the pain actually intensify the pain. The fight to tighten up in response to a painful experience or be angry that it hurts makes the pain worse. By accepting and investigating the emotions we experience with chronic pain with curiosity, rather than judgment, we can achieve substantial improvements in our well-being. Emotions are as real as the pain that causes them, and I firmly believe that if people with chronic pain don’t deal with their emotions about their pain, they will never get better.

Mel Pohl, M.D., is a Clinical Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Nevada School of Medicine.

About the Author
Mel Pohl M.D., FASAM

Mel Pohl, M.D., is a Clinical Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Nevada School of Medicine.

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